Provider Demographics
NPI:1700857091
Name:MALOUSE, MARK R (RPH)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:MALOUSE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
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Mailing Address - Street 1:2716 DAUPHINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70117-7322
Mailing Address - Country:US
Mailing Address - Phone:504-944-1114
Mailing Address - Fax:504-944-1114
Practice Address - Street 1:1010 COMMON ST
Practice Address - Street 2:SUITE A1460
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2401
Practice Address - Country:US
Practice Address - Phone:504-568-7097
Practice Address - Fax:504-568-8306
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA13787183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13787OtherPHARMACIST LICENSE